IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 29th day of February, 2024
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri.K.M.Anto, Member
CC No.292/2023 (Filed on 14/09/2023)
Complainant : Ancy George, W/o Late M.D. George,
Malathadathil House,
Ayarkunnam P.O,
Kottayam – 686 564,
(By Adv: E.T. Mathew)
Vs
Opposite parties : 1. Care Health Insurance Limited,
Vipur Tech Square,
Tower C, 3rd Floor,
Golf Course Road,
Sector - 43, Gurugram,
Haryana - 122 009.
2. Care Health Insurance Limited,
3rd Floor, Door No.55/686,
DI & DII, Vellathottam,
White Tower, Sahodaran Ayyappan Road,
Panampally Nagar,
Ernakulam – 682 036.
(Both by Adv: Agi Joseph)
O R D E R
Sri.Manulal V.S, President
The complaint is filed under Section 35 of the Consumer Protection Act 2019.
Case of the complainant is as follows:
The complainant availed health insurance policy from the opposite parties from 20-03-2022 to 19-03-2023 for a sum assured of Rs.10,00,000/- . The said policy was renewed for the period from 24-03-2023 to 23-03-2024. On 30-06-2023 while cooking, the complainant sustained burn injury on her right foot. Immediately she went to the St.Jude Hospital, Ayarkunnam and treated there as outpatient. As the injury is very serious in nature she was admitted in Marian Medical Centre, Palai on 5-07-2023 and treated there as an inpatient till 13-07-2023. An amount of Rs.20,820/- was spent by the complainant for her treatment at hospital. Though the claim for reimbursement is lodged with the opposite parties, the opposite parties repudiated the claim stating that there was no need for hospitalisation and the complainant could have been managed on outpatient department basis. According to the complainant the opposite parties illegally repudiated the genuine claim of the complainant and the act of the opposite parties amounts to deficiency in service and unfair trade practice. Hence this complaint is filed by the complainant praying for an order to direct the opposite parties to pay Rs.20,820/- to the complainant and to pay Rs.50,000/- as compensation for the loss and hardships caused to her by the act of the opposite parties and to pay Rs.10,000/- as the cost of this litigation.
Upon notice from this Commission opposite parties appeared before the Commission and filed joint version contending as follows:
The husband of the complainant was issued a health insurance policy namely ‘Care’ bearing policy number 39953039 from 20-03-2022 till 19-03-2023 covering only the complainant for an amount of Rs.10 lakhs subject to the policy terms and conditions. The policy was renewed till 23-03-2024. The policy along with terms and conditions duly delivered to the complainant and the complainant had the option to return or cancel the policy within free look period i.e. 15 days from the receipt of the policy documents, however till date no grievance or complaint has been raised in that regard. The cashless request was received from Marian Medical Centre, Arunapuram for the hospitalisation of the complainant from 5-07-2023 and as per the pre- authorization form she was hospitalised for treatment of superficial burn over the right foot. Upon receipt of the request the hospital was asked to provide certain documents necessary for adjudication of the request vide query letter dated 6-07-2023 and 8-07-2023. Upon perusal of the submitted medical records it is observed that there was no need for hospitalisation as no active course of treatment was given to her or any surgery was performed during her stay at the hospital. All the test reports were normal and she was managed through medicines. The complainant has not produced any document or certificate of treating doctor mentioning the reason for admission. The complainant could have been managed on OPD basis and admission was not justified. Therefore on the basis of aforesaid observation the claim was rejected on the grounds of admission not justified vide denial letter dated 11-07-2023. The claim of the insured has been rightly repudiated by the opposite parties in strict adherence to the policy terms and conditions and as such there is no deficiency in service on the part of the opposite parties.
Complainant filed proof affidavit and marked Exhibits A1 to A9. Sahil Chauhan who is the Manager(Legal) of the opposite parties filed affidavit and marked Exhibits B1 to B3.
On evaluation of the complaint, version and evidence on record we would like to consider the following points :
(1) Whether the complainant has succeeded to prove any deficiency in service or unfair trade practice on the part of the opposite parties?
(2) If so, what are the reliefs and cost?
For the sake of convenience we would like to consider Point Nos.1 and 2 together.
POINTS 1 & 2:-
There is no dispute on the fact that the complainant has availed a health insurance policy named ‘Care” from the opposite parties for the period from 20-03-2022 to 19-03-2023 and the same was renewed till 23-03-2024. On going through the Exhibit B1 policy certificate we can see that the sum assured was Rs.10 lakhs.
The specific case of the complainant is that she had sustained a burn injury on 30-06-2023 and immediately she had undergone treatment at St.Jude Hospital, Ayarkkunnam as an outpatient. As the injury was serious in nature she was shifted to Marian Medical Centre,Arunapuram, Pala and treated there as an inpatient from 5-07-2023 to 13-07-2023. The claim of the complainant for the refund of Rs.20,820/- which is the amount spent by her at the hospital towards the treatment expense was repudiated by the opposite parties on the ground that the hospitalisation is not justified.
It is proved by Exhibit A5 certificate issued by Dr,V.J Abraham that the complainant was treated as an outpatient at St Jude’s Hospital, Ayarkkunnam with a history of burn injury on foot sustained on 30-06-2023 and was treated with injection and other medications. On going through Exhibit A5 we can see that the doctor who treated the complainant advised the medicines for 3 days. Exhibit A3 is the discharge summary issued from the Department of General and Laparoscopic Surgery of Marian Medical Centre, Palai. On going through the Exhibit A3 we can see that the complainant was admitted in the hospital on 5-07-2023 and discharged on 13-07-2023. It is further stated in Exhibit A3 that the complainant presented in the hospital with a history of burn injury to right foot accidentally by hot oil on 30-06-2023 while cooking. It is further proved by Exhibit A3 that the complainant was treated with IV Antibiotics, Analgesics and other supportive care for superficial burn over right foot. Exhibit A9 which is the certificate issued by Dr.Jikupal M. Thomas on 13-07-2023 proved that the complainant came with a history of burn injury to right foot with hot oil on 30-06-2023 and was on oral antibiotics and came with complaint of pain, oedema, redness on right lower limb with pre-discharge from wound and diagnosed with wound infection/cellulitis right lower limb hence admitted in the hospital on 5-07-2023. Therefore it is proved that the complainant was admitted in Marian Medical Centre for the treatment to manage the infection which was due to the burned injury sustained by her.
The complaint was resisted by the opposite party stating that there is no need for hospitalisation and the complainant could have been treated with an outpatient basis.
In our opinion the doctors are the best to decide on admitting the patient to the hospital for the treatment. The doctor is the authority to decide the nature of the treatment to be given to his patients. When taking such decision, the primary factor in front of the doctor would be the patient’s health condition and well being only. The insurance company cannot construe it in the strict sense in a mechanical way on the basis of text book and records. The doctor cannot overlook the chance of any harmful reaction of the medicine administered and simply discharge the patient. So the admission of the patient as an inpatient may be necessary as the need of the hour. The repudiation of the claim by the insurance companies in such cases in a business perspective only by saying that for the treatment undergone by the insured no need for hospitalization, is only mechanical and against the objectives of the health insurance. It is proved by Exhibit A2 that the complainant had paid Rs.20,820/- to the Marian Medical Centre towards the treatment expenses. Denial of cashless facility without reasonable cause by the opposite party is considered a deficiency in service, as the insurer is not fulfilling its obligations to provide the benefits stipulated in the policy agreement.
On the basis of the above made discussions we are of the opinion that the opposite party has committed deficiency in service and unfair trade practice by not honouring the claim of the complainant. Due to the deficient act of the opposite party the complainant has put too much mental agony and hardships for which the opposite party is liable to compensate. In these circumstances we allow the complaint.
We hereby direct the opposite parties to pay Rs.20,820/- (Rupees Twenty Thousand Eight Hundred and Twenty only) to the complainant with 9% interest per annum from 11-07-2023. i.e. the date of rejection of the cashless benefits till the date of realisation.
We hereby direct the opposite parties to pay Rs.10,000/- (Rupees Ten Thousand only) as compensation to the complainant for the mental agony and hardships suffered by the complainant due to the deficiency of service on the part of the opposite parties.
The order shall be complied within 30 days from the date of receipt of copy of this order, failing which the compensation amount shall carry 9% interest from the date of this order till realisation.
Pronounced in the open Commission on this the 29th day of February, 2024
Sri.Manulal V.S, President Sd/-
Smt.Bindhu.R, Member Sd/-
Sri. K.M. Anto, Member Sd/-
APPENDIX :
Exhibits from the side of the Complainant :
A1 - Copy of Health Care Insurance Policy No.39953039
issued by the opposite parties
A2 - Copy of Discharge Bill dated 13/07/2023 for Rs.20,820/-
issued from Marian Medical Centre, Pala
A3 - Copy of Discharge Summary dated 13/07/2023
issued from the Department of General and Laparoscopic
Surgery of Marian Medical Centre, Palai
A4 (series) - Copy of claim denial letters (10 Nos.) issued by
the opposite parties
A5 - Certificate issued by Dr,V.J Abraham, St Jude’s Hospital,
Ayarkkunnam
A6(series) - Copy of photographs (3 Nos)of the right foot of the
complainant showing the burn injury
A7 - Copy of Notice dated 7/08/2023 issued by the complainant
to the opposite parties
A8 - Postal Receipt and Acknowledgement Card of Ext.A7 Notice
A9(series) - Justification letters dated 13/07/2023, 12/07/2023 and
7/07/2023 issued by Dr.Jikupal.M.Thomas, Marian
Medical Centre, Pala (3 in Nos)
Exhibits from the side of Opposite parties :
B1 - Copy of Policy with terms and conditions
B2 - Copy of denial of pre-authorisation for the complainant
B3(series) - Copy of query letters dated 5/07/2023 and 8/07/2023
By Order,
Sd/-
Assistant Registrar
